Rule 24. Notifying Physicians of Affidavits Alleging Abuse Pursuant to R.C. 2919.12

(A) Filing affidavits--procedure.

(1) Pursuant to R.C. 2919.12(B)(1)(b), a minor may have notice of an intended abortion given to a specified adult instead of one of her parents, guardian, or custodian. Two affidavits shall be filed with the clerk of the juvenile court by anyone seeking to invoke the notice provisions of the law. The first affidavit is executed by the minor and should be on "Form 24-A." The second affidavit is executed by the specified adult and should be on "Form 24-B." Anyone receiving these forms also shall be given the accompanying instruction sheet.

(2) Upon the filing of both affidavits and upon the request of the minor, her attorney, or the person who will perform the abortion, the clerk of the juvenile court shall issue a notice on "Form 24-C" verifying that the affidavits have been filed with the court.

(B) Confidentiality.

(1) All affidavits filed and notices issued pursuant to this rule shall be placed under seal in a safe or other secure place where access is limited to essential juvenile court personnel.

(2) Persons becoming aware of the contents of any affidavits prepared pursuant to this rule or R.C. 2919.12 are exempt from reporting such contents under R.C. 2151.421. Any reporting by court personnel would breach the duty of confidentiality and is prohibited by R.C. 102.03. FORM 24-A. AFFIDAVIT OF MINOR FORM 24-A. AFFIDAVIT OF MINOR JUVENILE COURT _____________ COUNTY, OHIO In re complaint of Jane Doe Case No._______________ AFFIDAVIT R.C. 2919.12(B)(1)(b)(ii) STATE OF OHIO ) ) COUNTY OF ) I, ____________________________________________, being duly sworn, state as follows: 1. I am pregnant, unmarried, under 18 years of age, and unemancipated. 2. I wish to have an abortion without notification of a parent, guardian, or custodian. 3. I request instead that notice of my intention to have the abortion be given to one of the following [Select One]: a. ________________________________, a brother or sister 21 years of Name age or older or, b. ______________________, a stepparent or grandparent. Name 4. I am in fear of physical, sexual, or severe emotional abuse from a parent, guardian, or custodian who otherwise would be notified of my intention to have an abortion pursuant to R.C. 2919.12. 5. My fear is based on a pattern of physical, sexual, or severe emotional abuse exhibited by a parent, guardian, or custodian. FORM 24-A. AFFIDAVIT OF MINOR (PAGE 2) 6. I understand that upon the filing of this affidavit and an affidavit from the person specified above with the juvenile court, an officer of that court will prepare a notice verifying that the affidavits have been filed. 7. The person who intends to perform or induce my abortion and the address of that person are as follows: ________________________________________ Name of Abortion Provider ________________________________________ Address ____________________________ Signature Before me appeared the above named person who under oath or by affirmation did sign this affidavit this ___________ day of, ___. __________________________________ Notary Public FORM 24-B. AFFIDAVIT OF RECIPIENT OF NOTICE OF MINOR'S INTENTION TO RECEIVE AN ABORTION FORM 24-B. AFFIDAVIT OF RECIPIENT OF NOTICE OF MINOR'S INTENTION TO RECEIVE AN ABORTION JUVENILE COURT COUNTY, OHIO In re complaint of Jane Doe Case No. AFFIDAVIT R.C. 2919.12(B)(1)(b)(iii) STATE OF OHIO ) ) COUNTY OF ) __________________________________________, being duly sworn, states as follows:

(Name) 1. I am [select appropriate one] ____ over 21 years of age and I am a brother or sister of ____ a stepparent or grandparent of __________________________, (hereafter, minor) who has [name of pregnant minor] filed an affidavit with the Juvenile Court pursuant to R.C. 2919.12(B)(1)(b)(ii). 2.

I have been specified in the minor's affidavit as the person to receive notice of the minor's intention to receive an abortion. 3. The minor has reason to fear physical, sexual, or severe emotional abuse from a parent, guardian, or custodian who otherwise would be notified of her intention to have an abortion pursuant to R.C. 2919.12. 4. Her fear is based on a pattern of physical, sexual, or severe emotional abuse exhibited by a parent, guardian, or custodian. ___________________________________ Signature Before me appeared the above named person who under oath or by affirmation did sign this affidavit this ______________ day of____________, . ___________________________________ Notary Public FORMS ALLEGING ABUSE BY PARENT AND REQUESTING THAT NOTIFICATION OF ABORTION BE PROVIDED TO OTHER RELATIVE INSTRUCTIONS FOR FORMS 24-A and 24-B If you use these forms, the person performing your abortion will not be required to give notice of your abortion to a parent, guardian, or custodian. Instead, you can choose to have notice provided to a brother or sister over 21 years of age or a stepparent or grandparent. These forms are called affidavits. An affidavit is a sworn statement signed before a person authorized to administer oaths, such as a notary public. The clerk's office will provide a notary public if you want to complete the forms in the clerk's office. These forms may be used if all of the following apply. You are: 1. Pregnant; 2. Unmarried; 3. Under 18 years old; 4. Unemancipated, which means that any of the following apply: • You have not entered the armed forces of the United States; • You do not have a job and support yourself; • You are under the care and control of a parent, guardian, or custodian. 5. You fear, based on events that have happened in the past, physical, sexual, or severe emotional abuse if notice of the abortion is given to a parent, guardian, or custodian. These forms will be filed with the juvenile court and kept confidential. The clerk of the court will provide notice to the abortion provider that the forms have been filed and the clerk will inform the abortion provider of the name of the person you have chosen to receive notice of your abortion. The forms will not be released by the court. You do not have to pay any filing fee or court costs to the clerk for notarizing these forms, filing these forms, or issuing the notice to the abortion provider. The affidavit must be filed in a juvenile court in the county where you reside or have a legal settlement or in any county that borders the county where you reside or have a legal settlement. HOW TO FILL OUT THE FORMS There are two forms. You complete one of them. The other form is completed by the person you select to receive notice of your abortion. That must be a brother or sister over 21 years old or a stepparent or grandparent. Your form requires that you name the person to receive notice and provide the name and address of the person to perform the abortion. Both of the forms must be signed in front of a notary public or other person, such as a judge or attorney, authorized to administer oaths. WHAT TO DO AFTER FILLING OUT THE FORMS After the forms are signed and notarized, give them to the juvenile court clerk, who will file them in a confidential place within the clerk's office. Then the clerk will issue a notice that you may take to the abortion provider. With that notice the abortion provider will be authorized to provide notice of the abortion to the brother, sister, stepparent, or grandparent that you have selected. FORM 24-C. NOTICE FORM 24-C. NOTICE JUVENILE COURT COUNTY, OHIO In re complaint of Jane Doe Case No. NOTICE Notice is hereby given that on_________, _____, (minor's name) filed affidavits pursuant to R.C. 2919.12(B)(1)(b)(ii) and (iii) and may therefore proceed to have any notifications required by that statute issued to the following specified adult: _____________________. ___________________________________ Clerk

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